Healthcare Provider Details

I. General information

NPI: 1891787040
Provider Name (Legal Business Name): DORRIE C TREDWAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DORRIE C CAPPELLETTI MD

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 N GREEN MOUNT RD SUITE 108
O FALLON IL
62269-2083
US

IV. Provider business mailing address

1512 N GREEN MOUNT RD SUITE 108
O FALLON IL
62269-2083
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-5510
  • Fax: 618-624-5529
Mailing address:
  • Phone: 618-624-5510
  • Fax: 618-624-5529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008010712
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036108951
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: